| National Provider Identifier [NPI]: | 1164499190 |
| Last Name Of The Provider | FORKS |
| First Name Of The Provider | THOMAS |
| Middle Initial Of The Provider | P |
| Credentials Of The Provider | DO |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 7275 S SIWELL RD |
| Street Address 2 Of The Provider | |
| City Of The Provider | JACKSON |
| Zip Code Of The Provider | 392729776 |
| State Code Of The Provider | MS |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Family Practice |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 69 |
| Number Of Services | 1123 |
| Number Of Medicare Beneficiaries | 217 |
| Total Submitted Charge Amount | 32838.97 |
| Total Medicare Allowed Amount | 27652.95 |
| Total Medicare Payment Amount | 18633.12 |
| Total Medicare Standardized Payment Amount | 21826 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 15 |
| Number Of Drug Services | 280 |
| Number Of Medicare Beneficiaries With Drug Services | 66 |
| Total Drug Submitted ChargeAmount | 1612.43 |
| Total Drug Medicare AllowedAmount | 1024.5 |
| Total Drug Medicare PaymentAmount | 771.41 |
| Total Drug Medicare Standardized Payment Amount | 771.41 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 54 |
| Number Of Medical Services | 843 |
| Number Of Medicare Beneficiaries With Medical Services | 217 |
| Total Medical Submitted Charge Amount | 31226.54 |
| Total Medical Medicare Allowed Amount | 26628.45 |
| Total Medical Medicare Payment Amount | 17861.71 |
| Total Medical Medicare Standardized Payment Amount | 21054.59 |
| Average Age Of Beneficiaries | 69 |
| Number Of Beneficiaries Age Less65 | 40 |
| Number Of Beneficiaries Age 65 to 74 | 105 |
| Number Of Beneficiaries Age 75 to 84 | 52 |
| Number Of Beneficiaries Age Greater 84 | 20 |
| Number Of Female Beneficiaries | 130 |
| Number Of Male Beneficiaries | 87 |
| Number Of Non Hispanic White Beneficiaries | 187 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 177 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 40 |
| Percent Of With Atrial Fibrillation | 7 |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | |
| Percent Of With Cancer | 6 |
| Percent Of With Heart Failure | 13 |
| Percent Of With Chronic Kidney Disease | 15 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 14 |
| Percent Of With Depression | 25 |
| Percent Of With Diabetes | 27 |
| Percent Of With Hyperlipidemia | 40 |
| Percent Of With Hypertension | 61 |
| Percent Of With Ischemic Heart Disease | 24 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 30 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 0.8482 |